Maine Department of Corrections

Maine Department of Corrections

Internship Program

25 Tyson Drive, SHS 111

Augusta, ME 04330

Applicant Information
Name:
/ DOB:
Address:
/ City:
State:
/ Zip:
/ E-mail:
Driver’s License:
/ State Issued:
/ Home Telephone:
/ Cellphone:
Emergency Contact Person
Name:
/ Relationship:
Address:
/ City:
State:
/ Zip:
/ E-mail:
Home Telephone:
/ Cellphone:
/ Work Telephone:
Availability
Beginning Date:
/ Ending Date:
Academic Background (list college/university from which you are pursuing or have received a degree)
Current College/University:
City:
/ State:
/ GPA:
Major/Area of Study:
/ Rank:
Type of Degree Pursued:
/ Date Degree Expected:
Current Academic Level: Freshman Sophomore Junior Senior Graduate
Faculty Advisor:
Department:
/ Telephone:
Military Record
Have you ever served on active duty in the Armed Forces of the United States? Yes No
Branch of Military Service:
/ Serial Number:
Date(s) of Service:
/ Type of Discharge:
Where Discharged:
/ Do you have a Service Connected Disability?
Yes No
Citizenship
Are you currently a U.S. Citizen?:
Yes No / Social Security #:
If Naturalized, Date of Entry:
/ Place of Entry:
Court:
/ Date:
/ Place:
Background Information
If you answer “YES” to any of the following questions, you must attach an explanation to this application;
include the date(s) and location(s) of conviction(s) and the disposition(s).
As an adult, have you ever been charged with a criminal offense (Class A, B, C, D, E)? / Yes / No
As an adult, have you ever been convicted of a criminal offense (Class A, B, C, D, E)? / Yes / No
As an adult, have you ever pled nolo contedere or pled guilty to a criminal offense (Class
A, B, C, D, E)? /
Yes / No
As an adult, have you ever had the adjudication of guilt withheld for a crime which is a
criminal offense (Class A, B, C, D, E)? / Yes / No
Skills
Please list any skills you possess that may be helpful to you as an intern:
Career Goals
Please list your career goal(s) or objective(s):

By signing below, I’m certifying that the information provide above is true and accurate to the best of my knowledge.

Applicant Signature:

Date:

Please return this completed application along with release forms, resume, transcript, referral letter and a copy of your photo id to:

Maine Department of Corrections

Human Resources

25 Tyson Drive, SHS 111
Augusta, ME 04333

Department of Corrections

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I, do hereby authorize the review of

and full disclosure of all records or any part thereof, concerning myself, by and to the Maine Department of Corrections, and any duly authorized agent of the Department of Corrections, whether said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of the records of employment and pre-employment records, information concerning past work, present work, attendance, evaluations, educational records (including transcripts), military service, criminal records, and any other personal record deemed necessary to verify the information provided in the application or during the selection process. Supplying erroneous information or omitting pertinent information as part of the application process would be sufficient cause for discharge.

I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life for the specific purpose of pursuing a background investigation, which may provide pertinent data for the Department of Corrections to consider in determining my suitability for employment. It is my specific intent to provide access to personal information, however personal or confidential it may appear to be, and the sources of information specifically identified herein.

I understand that any information obtained by a personal history background investigation, which is developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment by the Maine Department of Corrections. I understand that all materials pertaining to this background investigation become the property of the Maine Department of Corrections and will not be returned to me.

I agree to indemnify and hold harmless the person to whom this request is presented and all agents and employees from and against all claims, damages, losses and expenses, including reasonable attorney’s fees arising out of or by reason of complying with this request. I further understand that in the event my application is disapproved, the sources of confidential information cannot be revealed to me.

A photocopy of this release will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.

Signature: Date:

Name (Printed) Physical

Address:

DOB: S.S. No: Phone:

Witness: